Healthcare Provider Details

I. General information

NPI: 1104933258
Provider Name (Legal Business Name): JENNIFER WILLIAMS-MCDERMED O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA MCDERMED O.D.

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 LAKE UNDERHILL RD SUITE 236
ORLANDO FL
32828-4508
US

IV. Provider business mailing address

12301 LAKE UNDERHILL RD SUITE 236
ORLANDO FL
32828-4508
US

V. Phone/Fax

Practice location:
  • Phone: 407-277-5729
  • Fax:
Mailing address:
  • Phone: 407-277-5729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPC 4185
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberOPC 4185
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOPC 4185
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: